Palliative Pain management in the er UBC EM palliative medicine day Lindsay cohen july 27, 2016

1. Palliative Pain management in the erUBC EM palliative medicine dayLindsay cohenjuly 27, 2016

2. Objectives • Palliative pain management in the ER : • Basic approach • Opioid equivalencies • Adjuvant therapies • Common pitfalls

3. Case • Mr. C • 65 M, single, lives alone • Hx : prostate CA widely metastatic to bone • CC : severe, diffuse pain • “Hates” the health care system – has previously declined all treatment, but came into the ED because he is now desperate • Has been going to walk-in clinics for pain meds

4. Case • Pain “all over” • Difficulty mobilizing over the past week • In the past 2 days, has used : • “tons” of Advil • 50 x T#3 (Codeine 30 / Acetaminophen 325) • 50 x Percocet (Oxycodone 5 / Acetaminophen 325)

5. Case • Can’t-miss diagnoses?

6. Case • Can’t-miss diagnoses : • Hypercalcemia • Malignant spinal cord compression

7. Case • Ca normal • No focal neuro findings or clinical signs of SCC • You’ve decided that this is most likely pain from his bony mets • Orders?

9. Opioid Equivalencies • 2 x Tylenol #3 = 10 mg PO morphine • 2 mg PO hydromorphone = 10 mg PO morphine • 7.5 mg PO oxycodone = 10 mg PO morphine (x oxy by 1.5) • 25 mcg / h fentanyl patch = 60 – 130 mg PO morphine daily • 100 mcg IV fentanyl = 10 mg IV morphine • 1 mg Methadone * = 1 – 3 mg PO morphine * Applies only to Methadone used for pain (TID), not for addiciton (daily)

10. Equianalgesic Dosing • Convert current opioids to daily oral morphine equivalents (OME) • IV or SC dose = ½ of PO dose ie. 1 mg of Hydromorphone PO = 0.5 mg Hydromorphone IV/ SC • Breakthrough dose = 10% of total daily dose • Reduce calculated dose by 25 – 50% when switching to a new opioid to account for cross-tolerance • Start low, be prepared to increase quickly

11. STEP 1 : Convert to daily OME • 20 x T#3 = 100 mg PO morphine *** • 25 x 5 mg Oxycodone = approx. 200 mg PO morphine • Total = 300 mg PO morphine *** We will come back to T3s ***

12. STEP 2 : IV or SC dose = ½ of PO dose • 300 mg OME = 150 mg IV / SC morphine Now convert to your desired opioid (you can do this at any point) : • 150 mg morphine / 5 = 30 mg Hydromorphone

13. STEP 3 : Breakthrough dose = 10% of total daily dose • 30 mg Hydromorphone daily = 3 mg Hydromorphone breakthrough

14. STEP 4 : 50% reduction for cross-tolerance • 3 mg Hydromorphone breakthrough / 2 = 1.5 mg

15. STEP 5 : Start low, be prepared to increase quickly • 3 general presentations of palliative pain in the ED • Severe, acute pain crisis requiring multiple breakthrough doses within 1 h and rapid up-titration; may require an infusion • Moderate pain that is poorly controlled over the course of days – weeks despite reasonable therapy; may require IV analgesia • Mild-moderate pain that is poorly controlled but with suboptimal meds; often able to go home if med change and good follow-up

16. PATIENT 1 • Severe, acute pain crisis requiring multiple breakthrough doses within 1 h and rapid up-titration • Hydromorphone 1 – 2 mg IV q 15 min PRN ; call MD if ≥ 3 doses in 1 h • If requiring multiple doses of analgesia within 1 h and still severe pain, an infusion of fentanyl would be an appropriate next step • To calculate, remember 100 mcg IV fentanyl = 10 mg IV morphine • Consult palliative!

17. PATIENT 2 • Moderate pain that is poorly controlled over the course of days – weeks despite reasonable therapy; may require IV analgesia • Hydromorphone 1 – 2 mg IV q 1 h PRN

18. Talk to the RN! • DO NOT flag these orders and put them in the box to wait! • These patients are often inadequately treated : • Under-triage • Nursing discomfort with high-dose opioids / palliative care • DNR status

19. Adjuvants – Bone Pain

20. Adjuvants – Bone Pain ED MANAGEMENT • Opioids • Dexamethasone (8 mg PO / SC / IV bid) • + / - NSAIDS OTHER CONSIDERATIONS • Radiation • Bisphosphonates • Interventional / surgical (vertebroplasty)

21. Tylenol #3

22. Tylenol #3 • Hyper-metabolizers • Hypo-metabolizers • Potential for Acetaminophen toxicity if patient unaware of max.

23. What’s missing from this opioid prescription?

24. What’s missing from this opioid prescription? • Bowel protocol!

26. Case 2 • Mrs. T • 73 F with lung CA metastatic to brain and bone • Diffuse pain • Followed by GP, medical oncologist, radiation oncologist, pain and symptom management team

27. Case 2 Mrs. T’s Pharmanet : • Tylenol #3 1 – 2 tabs PO q4h PRN • Naproxen 500 mg PO bid • Hydromorphone ER 12 mg PO q12h • Hydromorphone 1 – 2 mg PO q4h PRN • Oxycodone 5 – 10 mg PO q1h PRN • Acetaminophen 650mg PO q4h PRN

28. Case 2 • Detailed medication history / pharmacist if available • These patients often have : • Multiple providers • Multiple medications / opioids • High incidence of medication-related side effects • Misunderstanding re: role of various medications, ie. regular vs. breakthrough vs. incident pain vs. adjuvants

29. Take Home Points • Use adjuncts to opioids; in ED = Dex (bone pain, SCC, SBO) • Find out what meds patients are ACTUALLY taking (not what PNET says) • Bowel protocol with opioid Rx – always • T#3 – bad • Calcium – vital sign in cancer patients • Talk directly with RNs when dealing with unusual / high dose opioid orders

30. Summary – Rotating Opioids • Convert current opioids to daily oral morphine equivalents (OME) • IV or SC dose = ½ of PO dose ie. 1 mg of Hydromorphone PO = 0.5 mg Hydromorphone IV/ SC • Breakthrough dose = 10% of total daily dose • Reduce calculated dose by 25 – 50% when switching to a new opioid to account for cross-tolerance • Start low, be prepared to increase quickly

31. References • The Pallium Palliative Pocketbook. 1st Edition. Pallium Canada; 2008. • Ipalapp.com. Providence Health Care Hospice Palliative Care Program • BC Cancer Agency Constipation Protocol. http://www.bccancer.bc.ca/family-oncology-network-site/Documents/SuggestionsforDealingwithConstipation.pdf • Palliative Medicine in the ED. Galicia-Castillo MC et al. emedjournal.com. August 1, 2015.